Professional Services Information Sheet(PSIS)UM 1669

Per the University’s Purchasinga Professional Service policy, this form is required:

For Non-PO related vouchers:

  • Totaling less than $3,000 and using sponsored funds:send the completed form to cluster with invoice or CRF (if no invoice). The cluster will link this form to the voucher in our document imaging system.

For Requisitions:

  • Totaling less than $3,000 and using sponsored funds:attach completed form to the requisition’s header comments. Do not click <Send to Supplier>.
  • Totaling $3,000 or greater: required for all professional services contracts, regardless of type. Attach completed form to the requisition’s header comments. Do not click <Send to Supplier>.

Complete all of this page’s fields below to summarizethe professional servicesbeing purchased.

Supplier’s Name
EFS Supplier ID Number
Supplier’s Address
Total Dollar Amount
Start & End Dates of Service
Contract Administrator’s Name and Email Address
Department Name
Please do not use acronyms.
Basis for Supplier Selection and Qualification
Explain how this supplier was selected and why.
Basis for Price
Explain the price breakdown, negotiated or hourly rate(s), any expenses, and payment schedule.
Price Reasonableness
Explain how the service provider delivers good value for the University and explain how the purchaser demonstrated stewardship of U funds for this purchase.

NOTE: Pages 2 and 3 of this form are conditionally required depending upon the following circumstances:

-Page 2: Only required if the supplier is an individual or sole proprietor. Do not include this section in the completed form if it is not applicable.

-Page 3: Only required if a sponsored project is paying for the services/expenses. Do not include this section in the completed form if it is not applicable.

Page 2: CompleteONLY if the Supplier is an Individual or Sole Proprietor

Answer all questions below. The information will be reviewed by a central tax analyst.

Does the individual have their own insurance for work-related injuries? / ☐Yes ☐No

Is the individual a University employee? (answer the questions immediately below)

Does the University or one of its system campuses currently employ this individual? / Was the individual on the University payroll (regular or temporary appointment) prior to the date these services are to begin? / Does the University plan to hire this individual as an employee soon after the period of their services as an independent contractor? / Is the individual currently working as an independent contractor for the University, and/or have they worked as an independent contractor for the University within the past 12 months?
☐Yes ☐No / ☐Yes ☐No / ☐Yes ☐No / ☐Yes ☐No

Will the service provider be a Lecturer or Instructor? ☐ Yes(answer the questions immediately below) ☐ No

Is the individual a “guest lecturer”, an individual who lectures infrequently, for example, at only one or two class sessions? / Is the individual the primary instructor in a department for a course being offered for academic credit toward a University degree? / Is the individual responsible for the content of the lecture/presentation (vs. presenting materials prepared/dictated by the University)?
☐Yes ☐No / ☐Yes ☐No / ☐Yes ☐No

Will the service provider be a Researcher? ☐Yes (answer the questions immediately below) ☐No

Will the individual serve in an advisory or consulting capacity with a University faculty member or director in a “collaboration between equals” type arrangement? / Will the individual perform research in an arrangement whereby a University faculty member or employee serves in a supervisory capacity? / Is the individual being paid as a grant participant as defined by the terms of the grant or account string being used?
☐Yes ☐No / ☐Yes ☐No / ☐Yes ☐No

If the service provider is NOT an Instructor, Lecturer, or Researcheranswer the questions immediately below:

Does the individual perform any of the following services (regardless of job title): actor, research project interviewer, medical residency program preceptor, assistant coach, medical care instructor, athletic band director, FDA reporting coordinator, or 4-H livestock coordinator? / Will the department provide the individual with specific instructions, supplies, and equipment to perform the required work, rather than rely on the individual’s expertise, supplies, and equipment? / Will the University set the number of hours or days that the individual is required to work, as opposed to allowing the individual to set their own work schedule?
☐Yes ☐No / ☐Yes ☐No / ☐Yes ☐No
Will the University pay the individual an hourly rate similar to what the Universitypays employees for similar work? / Does the individual engage in entrepreneurial activities in an established business at risk for loss? (This is an IRS definition.) / Does the individual routinely provide the same or similar services to other clients outside of the University as part of a continuing trade or business?
☐Yes ☐No / ☐Yes ☐No / ☐Yes ☐No

Page 3: CompleteONLY if the services are paid for by sponsored funds

Your Certified Approver(s) and Principal Investigator need the information below.

List the ChartField String(s) Used to Pay for the Services
Line / Dollar Amount / Fund / DeptID / Program / Project / Account / CF1 / CF2 / FinEmplID
1
2
3
  1. Select one of the options below to indicate how the price was negotiated with the supplier:

☐This is a firm price contract for a specific, well-defined project(s). The supplier agrees to provide the University with specific deliverables or outcomes for a mutually agreed-upon price.

-OR-

☐This contract is for non-employment project-related services as requested for the period indicated and atthe stated rates. Only services actually provided will be invoiced.

  1. Health Insurance Portability and Accountability Act (HIPAA) Data Collection:

Business Associates of health care components must be identified. All identified business associates must be reported to the Privacy Coordinator of the appropriate health care component, for tracking. Please respond to the questions below to facilitate compliance.

Does the contractor create, receive, transmit, or store Patient Health Information (PHI) on behalf of the University for services provided under this contract? ☐Yes ☐No

If yes, respond to all questions on the HIPAA Data Collection Sheet.Attach or link the completed HIPAA Data Collection formto this form (PSIS) and send it to your cluster. Your cluster will ensure the information is associated with the correct transaction in EFS.

  1. Answer these questions related to subawards/subcontracts:

Yes / No / Not Applicable / If using sponsored funds:
Is the work in the sponsored project’s approved budget classified as consulting or professional services?
Is the work in the sponsored project’s approved budget classified as subcontracting?
Are these programmatic activities that require a subaward/subcontract to be issued (if so, check yes)? Otherwise, is the work to be performed budgeted as independent consulting services (if so, check no)?
  1. Principal Investigator (or Authorized Designee) Approval Signature:

I have reviewed and authorize this purchase per University policy and sponsored guidelines:

Printed Name / Signature
Email Address / Date

Please type responses, handwriting can be difficult to read. Questions? (612) 624-1617
Revised8/1/17